6 Prescription Drugs 1 34-day Supply All Participating Pharmacies 90-day Supply All Participating Pharmacies Specialty Drugs Specialty pharmacy use and pre-authorization required, quantities vary Copayment - Applies for each covered prescription, unless noted, until out-of-pocket limit is met Generic You pay $15 Retail You pay $30 Mail You pay $60 Preferred You pay $25 Retail You pay $50 Mail You pay $60 Non-Preferred You pay $40 Retail You pay $75 Mail You pay $60 Deductible - $0 - the medical deductible does not apply to prescription drugs Out-of-Pocket Limit - Applies per calendar year for all copayments – the prescription drug out- of-pocket limit is separate from the medical out-of-pocket Individual $2,000 Family $4,000 Plan includes generic step therapy and prior authorization requirement for brand name drugs, compound drugs over $300, male androgens, and specialty medications. No copayment required for certain female contraceptives. 1 Note that under the medical plan, the schedule reflects what the plan will pay. However, under prescription drugs, the schedule reflects what you will pay per prescription fill for all plan options.